Accident Investigation Report Form
EMPLOYEE DETAILS
Name: ____________________________ Position:_____________________________
Address: _______________________________________________________________
INJURY DETAILS
Date of accident: ___________ Time: ________ Date Reported: __________ Time: _________
Date ceased work: __________ Time: __________ Supervisor: __________________________
Time lost (to date): ___________________ Time lost (anticipated overall) __________________
Medical Treatment required:
Nature and extent of injury
□ Head □ Trunk □ Multiple
Part of body injured □ Eyes □ Arm □ General
□ Neck □ Leg □ Unspecified
□ Sprain □ Laceration □ Burn
Nature of injury □ Fracture □ Concussion □ Superficial
□ Multiple □ Dislocation □ Amputation
□ Contusion □ Other
□ Flying □ Manual handling □ Electricity
object
Type of incident
□ Struck by □ Poisons □ Fall
□ Caught in □ Temperature □ Other
Describe the events leading up to the injury and how the injury occurred (witness or
injured person’s statement).
Witness Details
How did the accident happen
□ Ineffective □ Lack of protective □ Lack of training
guarding equipment
What caused the
accidents □ Lack of □ Safety rules not □ inexperience
maintenanc followed
e
□ Unsafe work □ Misconduct □ Workplace design
methods (equipment,
design, layout)
□ Weather □ Poor □ Language
housekeeping difficulties
Explain
How can a recurrence be prevented?
Accident Investigation - Supervisor’s Report
Supervisor’s name:
_______________________________________________________
Signature: _____________________________________ Date: ______________
Is this a Work-related injury? Yes/No
Employer/Supervisor comments:
